Ramsey County Board Workshop on State Hospital Utilization and Rising Costs - May 5, 2026
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Ramsey County Board Workshop on State Hospital Utilization and Rising Costs - May 5, 2026
On May 5, 2026, the Ramsey County Board held a workshop from 10:30 a.m. to approximately 12:00 p.m. (morning session) to discuss the increasing utilization of state-operated mental health services and the associated rising costs for the county. The workshop featured presentations from Ramsey County Social Services staff, the state's Direct Care and Treatment agency, and detailed case studies illustrating systemic challenges. The afternoon session was scheduled to focus on cost trends and trade-offs.
Discussion Items
- Opening Remarks: Chair Jevon Singh and County Manager Becker welcomed participants. Presenters included Matt Clark (Health Monitor Unity), Karen Francisco (Manager of Medical Services), Monica Long (Director of Community Services), Christy Pops, and Deputy Director Walker.
- State Operated Services Overview: Eric A. Dawson (Transitions and Liaison Director, Minnesota Direct Care and Treatment) explained that Direct Care and Treatment became a standalone agency on July 1, 2025, serving about 12,000 individuals annually, primarily those civilly committed. The system includes five core service lines: mental health and substance use treatment (hospitals and residential), forensic services (forensic mental health program with ~400 beds), community-based services (adult foster care, crisis residences), clinical services (psychiatric care, pharmacy), and the Minnesota Sex Offender Program (~800 beds). The agency operates 150 sites with a budget of $186 million and about 5,500 employees. Occupancy runs at 95% daily, with the 5% variance due to transport delays or temporary bed closures.
- Civil Commitment Process: Kenya (deputy director) explained that under statute 253B.10, individuals are placed in the least restrictive setting, but those with highest needs or safety risks often go to state hospitals. Priority is given to individuals from jails or correctional settings and those needing competency evaluations. This prioritization creates a situation where people in the community may need to decompensate or become justice-involved to access care—a reality confirmed by presenters.
- Case Study - Jordan: A 29-year-old male with serious mental illness, cognitive impacts from prenatal alcohol exposure, polysubstance use, and trauma history. He was civilly committed five years ago after assaulting shelter staff. He has had five provisional discharges revoked and has been recommitted multiple times. More than 20 programs declined to accept him due to behavioral intensity and liability concerns. He has been in a state facility since November 2025 and has not met criteria to remain there since June 2025. A customized placement was created through Ramsey County's Innovations Grant bed hold program, requiring a moratorium exception and extensive coordination. The process began in September 2025 and was ongoing as of the meeting.
- Case Study - Derek: A 39-year-old male with mental illness and substance use, involved with Ramsey County's adult mental health system for over 15 years. He had periods of stability (worked in construction and a grocery store) but cycled through multiple hospitalizations, homelessness, and justice involvement. Despite ACT, supportive housing, and family involvement, he eloped from a specialized placement and was later arrested for sexual assault. He is currently at Anoka Metro Regional Treatment Center (AMRTC) awaiting a bed at the forensic mental health program in St. Peter, with pending commitment as mentally ill and dangerous.
- Barriers to Discharge: Sophia (presenter) outlined that community supports are insufficient for the complexity of individuals. Housing remains a major barrier; for Jordan, a single-resident customized home was required due to lack of existing options. Workforce capacity and skills gaps in group homes were highlighted, with staff often paid in the high teens per hour despite risk of injury. Integration of mental health and chemical health services is lacking.
- Ramsey County's Role: Two structured utilization meetings are held every Monday—one internal (morning) and one with external partners (afternoon). These meetings review all state hospital patients, identify discharge barriers, and coordinate funding pathways. A pilot position for MinChoices and financial assistance was added via grant funds to speed eligibility processes. The county reported a significant reduction in length of stay after patients no longer meet medical criteria, though exact numbers were not provided.
- Commissioner Questions & Positions:
- Commissioner McMurtry asked whether the gap is in provider capacity or specific services; presenters said it's multi-layered, including staffing, insurance pressures, and liability.
- Commissioner Jennings asked about the historical shift from institutionalization to community-based care, noting the 1990s shift to managed care and the Olmstead v. LC Supreme Court decision without adequate resources. Presenters agreed the system was not fully actualized.
- Commissioner Moran questioned whether the system is just making room for the next patient, but presenters explained policies like the 90-day max stay in ERTS facilities create bottlenecks.
- Commissioner Ortega noted that after 25 years, the same issues persist: lack of capacity and private sector involvement. He emphasized the need to reshape the environment with private sector partnerships.
- Commissioner Zhang highlighted the lack of incentives for providers due to insurance company determinations and the need for statewide solutions, not just property tax burdens.
- Commissioner Shaw expressed concern about workforce shortages and group home viability, predicting more closures in 5-10 years.
- Commissioner Singh asked about an ecosystem map of providers and gaps; presenters agreed to work on identifying gaps but noted that even with all services, individual fit is nuanced.
- Data Points: Presenters noted that a very small subset of the 1 in 20 adults with serious mental illness are represented in these cases. The Innovations Grant bed hold program is a Ramsey County-led initiative funded three years ago, with a handful of other counties having similar programs. Hennepin and Ramsey are the highest utilizers of state-operated services.
Key Outcomes
- No formal decisions or votes were taken during the morning session, as it was a workshop designed to provide foundational understanding.
- Directives: The board expressed interest in receiving a document with hot links to relevant state and national initiatives, reports, and work groups to support deeper learning.
- Next Steps: The afternoon session was scheduled to focus on cost trends, financial burdens, and difficult trade-offs. Presenters indicated the workshop would inform future policy, investment, and advocacy decisions.
- Recognition: Chair Jevon Singh thanked Eric Dawson and Direct Care and Treatment for their partnership. The board acknowledged the need for a multi-pronged approach involving legislative advocacy, private sector engagement, and system redesign to address chronic capacity and funding gaps.
Meeting Transcript
Matt Clark Health Monitor Unity providing. Karen Francisco Manager of Medical Services and Supports. Possibly hear me telling the value of planning managers on this. Monica Long Director of Community Burger Chance. No way controller health problems. Christy Pops can I think nothing? Excellent. Today's discussion is about understanding why state hospital use is increasing and what is driving rising costs for the county. There are broader system pressures across behavioral health, housing, and justice systems. We want to ground this conversation who is being served, why they're there, and what happens when systems don't align. This conversation will help frame future policy investment and advocacy decisions. This morning focuses on people, utilization and discharge challenges. And the afternoon will focus on costs, trends, and difficult trade-offs. And as these comments stay, you know, we're going to be talking about dollars and policies and stats and numbers. But because that is our job as a policy-making body, but also that there are people and individuals behind each and every one of these statistics that we evolve very dear, and there are staff who are working to make sure that their care and custody is the best it can be. So we honor that as we have this discussion. With that, I will hand it off to our presenters. Thank you, Chair, Commissioners, County Manager, guests. Before we deep dive into this, I wanna thank uh Director Thompson, um, Deputy Director Walker for their leadership, um, the external partners that are here with uh with us today, and all of the other social service um managers and employees that have been working diligently on this uh topic as well. So thank you all for doing that work. Um so today we want to take a closer look to how the state operated care impact Ramsey County, both in terms of our system capacity and the individuals we serve. Uh we're also seeking uh clear shift within the behavioral health system, greater complexity, higher equity, um, and more individuals needing intensive level of care. As clients need to grow more complex, we're operating within a system that is often under understructed, under uh constructed and fragmented. As a result, we're not always able to fully meet the needs of our residents that we serve. But this um at the same time, there are gaps across the continuum of care that will make it difficult to move people through the systems into a stable appropriate placement. And response will strengthen our partnership with community, state, and local providers to better navigate these challenges and address both trends and gaps we are seeking. This workshop today is intended for two parts. Um, there's a lot of information that we will go through. The first part of the workshop today is going to be designed for the people side of things to show what our clients and residents are going through the process, and in the afternoon, we'll be focusing more on the system, um, the challenges, the barriers, um, the financial burden the county has. Um, and and we'll go into those details. Um, I know there's a lot of uh detailed information that we'll go through, so we um hope that we can go through this um workshop uh with you all. I know it's a lot of information. We hope to address the questions you have, hopefully at the end of the workshop. And with that, I will um hand it off to uh director Thompson to kick us off. Good morning, Chair Jevon Singh, County Manager, excuse me, county board and uh county manager Becker. Um this is a really complex topic, and we really thought long and hard about how to present this because it's a lot of information. And so I want a level set with that at the beginning here, so we can settle in. So we we intentionally said, let's do a morning workshop and let's do an afternoon workshop that allows us to get the breath. That allows us to get the breath. We know there'll be a lot of questions, and um, you'll see there'll be some natural points for that. But we're here this morning to tell a story. And we are going to tell that story through the eyes of um two individuals whose identity has been protected. And um, and when Charles comes up, he's gonna talk to you about um Jordan and Derek. And I we're gonna walk you through this. And so there is a moment where we're gonna ask you to kind of sit back and really listen about how people experience the system. And so I wanted to start with that because this is a really large and um complex, complex system, not just the individuals who experience civil commitment, but those who come through our state operated services. Um, we have some goals for you today. They include we really want you to have a foundational information about state operated services and state operated services sometimes in the past has been called direct care and treatment, interchangeable based on what time you've been involved with understanding state operated services. But we want you to understand that landscape and of who utilizes those services and those complex situations, because not everyone, as was mentioned in the morning a little bit ago. There are so many people who experience mental health as we are in mental health awareness month, right?
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